- Email: [email protected]
Misdiagnosis of fetal life from an artifact in the electrocardiogram
Volume Number
94 2
Sex chromatin in the buccal epithelium was negative, 17-ketosteroids in the urine were 8.30 mg. Per 24 hours, 17-OH corticosteroids were 5.6 mg. per 24 hours, urinary gonadotropins were below 4 M.U.U. per 24 hours. Exploratory laparotomy was Performed. No internal genitals were found. In the right inguinal canal an ovoid testicle (3 x 2 x 2 cm.) was present. On the left no gonad was found. The testicle was biopsied by removing a 2 x 1 cm. segment. It was covered with a fibrous tunica albuginea. The testicular tissue was examined histochemically. Alkaline and acid phosphatase, nonspecific a-naphthyl esterase, lactic dehydrogenase, succinic dehydrogenase, 3/301 steroid dehydrogenase, glycogen, and other saliva-resistant P.A.S.-positive substances were demonstrated. The histochemical technique was the same as described previous1y.s The histologic structure of the testicular tissue is shown (Fig. 2). The seminiferous tubules are relatively narrow. They contain Sertoli cells and some spermatogonia. The basement membranes of the tubules are slightly thickened. The interstitial connective tissue is loose. Leydig cells (interstitial epithelioid cells) are not present. Spermatogonia contain alkaline phosphatase and nonspecific esterase. In the Sertoli cells lactic dehydrogenase, glycogen, and acid phosphatase were demonstrated. Single fibroblast-like cells of the interstitium contain strong nonspecific esterase and lactic dehydrogenase activity. No activity of 3&01 steroid dehydrogenase could be demonstrated in any tissue of this testicle. Our patient differs from the classical form of testicular feminization described by Morris1 by the lack of development of the breasts, by vaginal aplasia, by the absence of Leydig cells in the testicle, and by the low urinary gonadotropin content. This low content of urinary gonadotropins is in agreement with the absence of Leydig cells in the testicle as well as with the absence of 3/3-01 steroid dehydrogenase activity in the gonad. The histologic structure of
Communications
in brief
287
the testicle resembles the testicle of male hypogonadotropic eunuchoids. This finding shows that steroid production in such a testicle is probably very insufficient. The insufficiency in testicular steroid production must be related to the lack of development of the breasts and the eunuchoid habitus of our patient. It is also in agreement with the concept of Hausers that the length of the vagina in testicular feminization is proportional to the testicular insufficiency. (In our case the vagina was absent.) We are of the opinion that our patient is a hypogonadotropic eunuchoid form of the testicular feminizing syndrome. We know no other case from the literature. A new form of male pseudohermaphroditism, the so-called eunuchoid hypogonadotropic form of testicular feminizing syndrome, in a 17-yearold patient has been described. REFERENCES 1.
2. 3.
Morris, J. McLean: AM. J. OBST. & GYNEC. 65: 1192, 1953. Jirbsek, J. E., and Raboch, J.: Fertil. & Steril. 14: 237, 1963. Haused, G. A.: Testicular feminization. In Overzier, C., editor: Intersexuality, London and New York, 1963, Academic Press, Inc.
Misdiagnosis of fetal life from artifact in the electrocardiogram* HERMAN
I.
KANTOR,
an
M.D.,
F.A.C.O.G. ALBERT PHILIP
BOWMAN, D.
ABBOTT,
M.S. JR.,
M.D.,
F.A.C.O.G. Department of Obstetrics-Gynecology, St. Paul Hospital, Dallas, Texas
Fig. 2. Histologic picture of the testis. Seminiferous tubules are narrow and their basal membranes are slightly thickened. In the interstitium no Leydig cells. (Hematoxylin and eosin. x80.)
W H E N a new instrument or a new technique is employed in medical practice, the physician is generally hypercritical in his evaluation of its worth. Such an approach is sound because it permits selection on merit primarily, a commendable attitude. However, when the details of the-, technique have been inadvertently breach&. and the instrument is used incorrectly, conclusions should be admitted wrong and the bad impressions dissipated. This was our dilemma in the 2 cases to be presented. *Supported
by the
Weinberger
Research
Fund.
For
legends
see opposite
page.
Volume Number
94 2
Communications
Taking
an
electrocardiogram
of
the
fetus
in
utero is an old idea currently approached with new and more useful instruments, Among these is the radioelectrocardiograph* which combines advanced electronic circuitry with a new presentation. To eliminate electrical interference usualiy present in a hospita1 environment, the signal is picked up by a battery-operated receiver and transmitted by shortwave to another location where it then operates the electrocardiograph. The patient is free to move about unhampered by a cable connected to a wall electric outlet. The principal function of the fetal electrocardiograph is to diagnose life or death while the fetus is yet undelivered. Plus values may include detection of fetal cardiac abnormalities, signs of distress, breech presentation, twin pregnancy, and others. However, if the apparatus fails in its major ration d’he, the additional advantages pale to insignificance. In the following 2 patients, fetal life was misdiagnosed because of an error in the technique of operating our machine. They are reported for three reasons: (I) to alert others that operational errors with this electrocardiograph apparatus may lead to such misdiagnosis. (Figs. 1 and 2) ; (2) to point out that with little experience this electronic system has proved its worth; and (3) the pickup of the fetal heart from electrodes placed on the maternal abdomen is practical and useful. We are now able to record signal in more than 95 per *RKG
500,
T&medics,
accurately cent of our
Southhampton,
Case 1. Mrs. J. L. was aged 23, gravida ii, para i, with an estimated date of confinement of May 17, 1965. The onset of cramps and bleeding on January 25 was treated conservatively with objective improvement. The fetal heart was not heard but the fetal ECG (Fig. 3) was interpreted to indicate a live baby. Several days later, the patient suddenly had a placental abruption. Fetal death was suspected clinically, but with the indication that a fetal heart complex was seen on the tracing, cesarean section was done. A macerated, mummified male fetus weighing 1 pound, 2 ounces was delivered. The error in the electrocardiographic tracing was admitted, but its cause was only recognized later. Case 2. Mrs. E. W. was aged 28, gravida iv, para iii, with an estimated date of confinement of July 22, 1965. She complained on June 21 that she did not feel the baby move. Fetal heart tones, previously heard easily, were not detected. The fetal ECG (Fig. 4) was interpreted as diagnostic of a live baby. Several days later she was delivered of a stillborn, hydrocephalic, macerated infant. Again the incorrect diagnosis was puzzling. The junior author discovered the technical error we were making in the operation of this apparatus. This possibility was not indicated in the instruction manual for this machine.’ The correction has given us a relatively easy, reliable aid in the diagnosis of a living or dead fetus in utero. When indicated, the fetal electrocardiogram may correctly influence delivery decisions. 712 N. Washington Dallas, Texas
be
1. Signal
Fig.
2. Fetal
Fig.
3. Tracing
from
Case
1. Artifact
misinterpreted
as live baby.
Fig.
4. Tracing
from
Case 2. Artifact
misinterpreted
as live
heart
misinterpreted
“The used
Fig.
and maternal
tracing
289
the feta1 patients.
Pennsybmnia.
from.electrocardiograph
in brief
with
artifact
as fetal
T position on the lead during actual operation
heartbeat.
superimposed.
baby.
selection of the
switch machine.
must
not
94 2
Sex chromatin in the buccal epithelium was negative, 17-ketosteroids in the urine were 8.30 mg. Per 24 hours, 17-OH corticosteroids were 5.6 mg. per 24 hours, urinary gonadotropins were below 4 M.U.U. per 24 hours. Exploratory laparotomy was Performed. No internal genitals were found. In the right inguinal canal an ovoid testicle (3 x 2 x 2 cm.) was present. On the left no gonad was found. The testicle was biopsied by removing a 2 x 1 cm. segment. It was covered with a fibrous tunica albuginea. The testicular tissue was examined histochemically. Alkaline and acid phosphatase, nonspecific a-naphthyl esterase, lactic dehydrogenase, succinic dehydrogenase, 3/301 steroid dehydrogenase, glycogen, and other saliva-resistant P.A.S.-positive substances were demonstrated. The histochemical technique was the same as described previous1y.s The histologic structure of the testicular tissue is shown (Fig. 2). The seminiferous tubules are relatively narrow. They contain Sertoli cells and some spermatogonia. The basement membranes of the tubules are slightly thickened. The interstitial connective tissue is loose. Leydig cells (interstitial epithelioid cells) are not present. Spermatogonia contain alkaline phosphatase and nonspecific esterase. In the Sertoli cells lactic dehydrogenase, glycogen, and acid phosphatase were demonstrated. Single fibroblast-like cells of the interstitium contain strong nonspecific esterase and lactic dehydrogenase activity. No activity of 3&01 steroid dehydrogenase could be demonstrated in any tissue of this testicle. Our patient differs from the classical form of testicular feminization described by Morris1 by the lack of development of the breasts, by vaginal aplasia, by the absence of Leydig cells in the testicle, and by the low urinary gonadotropin content. This low content of urinary gonadotropins is in agreement with the absence of Leydig cells in the testicle as well as with the absence of 3/3-01 steroid dehydrogenase activity in the gonad. The histologic structure of
Communications
in brief
287
the testicle resembles the testicle of male hypogonadotropic eunuchoids. This finding shows that steroid production in such a testicle is probably very insufficient. The insufficiency in testicular steroid production must be related to the lack of development of the breasts and the eunuchoid habitus of our patient. It is also in agreement with the concept of Hausers that the length of the vagina in testicular feminization is proportional to the testicular insufficiency. (In our case the vagina was absent.) We are of the opinion that our patient is a hypogonadotropic eunuchoid form of the testicular feminizing syndrome. We know no other case from the literature. A new form of male pseudohermaphroditism, the so-called eunuchoid hypogonadotropic form of testicular feminizing syndrome, in a 17-yearold patient has been described. REFERENCES 1.
2. 3.
Morris, J. McLean: AM. J. OBST. & GYNEC. 65: 1192, 1953. Jirbsek, J. E., and Raboch, J.: Fertil. & Steril. 14: 237, 1963. Haused, G. A.: Testicular feminization. In Overzier, C., editor: Intersexuality, London and New York, 1963, Academic Press, Inc.
Misdiagnosis of fetal life from artifact in the electrocardiogram* HERMAN
I.
KANTOR,
an
M.D.,
F.A.C.O.G. ALBERT PHILIP
BOWMAN, D.
ABBOTT,
M.S. JR.,
M.D.,
F.A.C.O.G. Department of Obstetrics-Gynecology, St. Paul Hospital, Dallas, Texas
Fig. 2. Histologic picture of the testis. Seminiferous tubules are narrow and their basal membranes are slightly thickened. In the interstitium no Leydig cells. (Hematoxylin and eosin. x80.)
W H E N a new instrument or a new technique is employed in medical practice, the physician is generally hypercritical in his evaluation of its worth. Such an approach is sound because it permits selection on merit primarily, a commendable attitude. However, when the details of the-, technique have been inadvertently breach&. and the instrument is used incorrectly, conclusions should be admitted wrong and the bad impressions dissipated. This was our dilemma in the 2 cases to be presented. *Supported
by the
Weinberger
Research
Fund.
For
legends
see opposite
page.
Volume Number
94 2
Communications
Taking
an
electrocardiogram
of
the
fetus
in
utero is an old idea currently approached with new and more useful instruments, Among these is the radioelectrocardiograph* which combines advanced electronic circuitry with a new presentation. To eliminate electrical interference usualiy present in a hospita1 environment, the signal is picked up by a battery-operated receiver and transmitted by shortwave to another location where it then operates the electrocardiograph. The patient is free to move about unhampered by a cable connected to a wall electric outlet. The principal function of the fetal electrocardiograph is to diagnose life or death while the fetus is yet undelivered. Plus values may include detection of fetal cardiac abnormalities, signs of distress, breech presentation, twin pregnancy, and others. However, if the apparatus fails in its major ration d’he, the additional advantages pale to insignificance. In the following 2 patients, fetal life was misdiagnosed because of an error in the technique of operating our machine. They are reported for three reasons: (I) to alert others that operational errors with this electrocardiograph apparatus may lead to such misdiagnosis. (Figs. 1 and 2) ; (2) to point out that with little experience this electronic system has proved its worth; and (3) the pickup of the fetal heart from electrodes placed on the maternal abdomen is practical and useful. We are now able to record signal in more than 95 per *RKG
500,
T&medics,
accurately cent of our
Southhampton,
Case 1. Mrs. J. L. was aged 23, gravida ii, para i, with an estimated date of confinement of May 17, 1965. The onset of cramps and bleeding on January 25 was treated conservatively with objective improvement. The fetal heart was not heard but the fetal ECG (Fig. 3) was interpreted to indicate a live baby. Several days later, the patient suddenly had a placental abruption. Fetal death was suspected clinically, but with the indication that a fetal heart complex was seen on the tracing, cesarean section was done. A macerated, mummified male fetus weighing 1 pound, 2 ounces was delivered. The error in the electrocardiographic tracing was admitted, but its cause was only recognized later. Case 2. Mrs. E. W. was aged 28, gravida iv, para iii, with an estimated date of confinement of July 22, 1965. She complained on June 21 that she did not feel the baby move. Fetal heart tones, previously heard easily, were not detected. The fetal ECG (Fig. 4) was interpreted as diagnostic of a live baby. Several days later she was delivered of a stillborn, hydrocephalic, macerated infant. Again the incorrect diagnosis was puzzling. The junior author discovered the technical error we were making in the operation of this apparatus. This possibility was not indicated in the instruction manual for this machine.’ The correction has given us a relatively easy, reliable aid in the diagnosis of a living or dead fetus in utero. When indicated, the fetal electrocardiogram may correctly influence delivery decisions. 712 N. Washington Dallas, Texas
be
1. Signal
Fig.
2. Fetal
Fig.
3. Tracing
from
Case
1. Artifact
misinterpreted
as live baby.
Fig.
4. Tracing
from
Case 2. Artifact
misinterpreted
as live
heart
misinterpreted
“The used
Fig.
and maternal
tracing
289
the feta1 patients.
Pennsybmnia.
from.electrocardiograph
in brief
with
artifact
as fetal
T position on the lead during actual operation
heartbeat.
superimposed.
baby.
selection of the
switch machine.
must
not